Systematic review, level III.

Background: Mortality caused by Traumatic Brain Injury (TBI) remains high, despite improvements in trauma and critical care. Polytrauma is naturally associated with high mortality. This study compared mortality rates between isolated TBI ( I TBI) patients and polytrauma patients with TBI ( P TBI) admitted to ICU to investigate if concomitant injuries lead to higher mortality amongst TBI patients.Methods: A 3-year cohort study compared polytrauma patients with TBI ( P TBI) with AIS head ≥3 (and AIS of other body regions ≥3) from a prospective collected database to isolated TBI ( I TBI) patients from a retrospective collected database with AIS head ≥3 (AIS of other body regions ≤2), both admitted to a single level-I trauma center ICU. Patients <16 years of age, injury caused by asphyxiation, drowning, burns and ICU transfers from and to other hospitals were excluded. Patient demographics, shock and resuscitation parameters, multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and mortality data were collected and analyzed for group differences.Results: 259 patients were included; 111 P TBI and 148 I TBI patients. The median age was 54 years, 177 (68%) patients were male, median ISS was 26 [20][21][22][23][24][25][26][27][28][29][30][31][32][33]. Seventy-nine (31%) patients died. Patients with P TBI developed more ARDS (7% vs. 1%, p=0.041) but had similar MODS rates (18% vs. 10%, p=0.066). They also stayed longer on the ventilator (7 vs.3 days, p=<0.001), longer in ICU (9 vs. 4 days, p=<0.001) and longer in hospital (24 vs. 11 days, p=<0.001). TBI was the most prevalent cause of death in polytrauma patients. Patients with P TBI showed no higher in-hospital mortality rate. Moreover, mortality rates were skewed towards I TBI patients (24% vs. 35%, p=0.06).Discussion: There was no difference in mortality rates between P TBI and I TBI patients, suggesting TBI-severity as the predominant factor for ICU mortality in an era of ever improving acute trauma care.

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BackgroundAn important critique with respect to the utilization of intermediate care units (IMCU) is that they potentially admit patients who would otherwise be cared for on the regular ward. This would lead to an undesired waste of critical care resources. This article aims to (1) describe the caseload at the IMCU and (2) to assess the triage system at the IMCU to determine potentially unnecessary admissions.MethodsThis cohort study included all admissions at the mixed-surgical IMCU from 2001 to 2015. The Therapeutic Intervention Scoring System-28 (TISS-28) was prospectively collected for all admissions to describe the caseload at the IMCU and to identify medical criteria for admission. These were combined with logistical criteria to assess the IMCU triage system.ResultsA total of 8816 admissions were included in the study. The average TISS-28 was 20.19 (95% CI 18.05 to 22.33), corresponding with 3.57 (95% CI 3.19 to 3.94) hours of direct patient-related work per patient per nursing shift. Over time, this increased by an average of 0.27 points/year (p<0.001). Of all admissions, 6539 (74.2%) were medically considered to be justly admitted, and 7093 (80.4%) were logistically considered to be justly admitted. With these criteria combined, a total of 8324 (94.4%) were correctly admitted.DiscussionMost admissions to the IMCU are medically and/or logistically necessary, as the majority of admitted patients demand a higher level of nursing care than available on the general ward. Continuous triage is thereby essential. These findings support further utilization of the IMCU in our current healthcare system and has important implications for IMCU-related management decisions.Level of evidenceLevel VI.